Complaint Investigation

Evergreen Post Acute

April 17, 2025 · Smyrna, DE · 3034 South Dupont Blvd

Citations 3

CMS Rating 2/5

Beds 151

Provider ID 085020

Healthcare Facility

Evergreen Post Acute

Smyrna, DE · View full profile →

Source Document

Official CMS Inspection Report (Medicare.gov) · 16 pages

Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.

Inspection Summary

EVERGREEN POST ACUTE in SMYRNA, DE — inspection on April 17, 2025.

Found 3 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF677

Minimal harm or included assist with daily hygiene, grooming, dressing, oral care, and eating as needed. Some and required substantial maximum assistance for personal hygiene and grooming. affected

Review of R130's clincial record revealed:

3/7/25 - R130 was admitted to the facility.

085020

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 085020 B.

Wing 04/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Evergreen Post Acute 3034 South Dupont Blvd Smyrna, DE 19977

FF760

Minimal harm or Evergreen prior to discharge. Few affected

The facility failed to initiate EBP for R14 until eight months (from 4/1/24 to 11/22/24) after the new guidelines were mandated.

4/16/25 - 12:01 PM -

During an interview, E2 (DON) confirmed that R14 has had a colostomy since he has been in the facility.

Review of R639's clinical record revealed:

6/21/24 - R639 was admitted to the facility with diagnoses including but not limited to, chronic obstructive pulmonary disease.

085020

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 085020 B.

Wing 04/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Evergreen Post Acute 3034 South Dupont Blvd Smyrna, DE 19977

FF880

Minimal harm or and no one would listen to me until I saw the dermatologist. R112 stated that he did not receive showers until An interview with E38 (CNA) confirmed that R112 was on isolation precautions and affected

7/30/24 - R112 was admitted to the facility.

8/27/24 3:12 PM - A physician's order documented that R112 was on contact isolation due to scabies for fourteen days.

11/9/24 - A physicians order was written for R112 consult to dermatology related to scabies.

11/13/24 - A specialist physician's (dermatologist) progress note documented that R112 was not contagious and to remove isolation precautions.

4/15/25 10:30 AM - An interview with C2 (NP) and C5 (NP) confirmed that R112 was on contact precautions from 8/27/24 to 11/13/24.

There was a ten week delay in consulting the dermatologist resulting in R112 being in isolation for 78 days.

47621

2. R644's clinical record revealed:

Cross refer

Frequently Asked Questions

What is an F-tag violation?

F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.

Were these violations corrected?

Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.

How often do nursing home inspections happen?

CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.

What should families do about these violations?

Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in SMYRNA, DE, (5) Report new concerns to state authorities.

Where can I see the full inspection report?

Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from EVERGREEN POST ACUTE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.

More Reports

About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.